Exporting American mental illness

The New York Times Magazine has a great discussion of the effects of the exportation of American ideas about mental illness, titled appropriately, The Americanization of Mental Illness by Ethan Watters, based on his forthcoming book, Crazy Like Us: The Globalization of the American Psyche, coming out this month from Free Press. The article is quite good, offering some intriguing cases, such as the rise of virulent, American-style anorexia nervosa in Hong Kong, the effect of possession beliefs on communities’ reactions to schizophrenia, and how the narrative of mental illness as ‘brain disease’ might actually lead to great stigma as it spreads and replaces local understandings. The article is well worth a read, and I’m looking forward to the book.

graphic by Alex Trochut, NYTimes

The ethnographic record is full of conditions that didn’t make it into the most recent edition of the DSM — amok, nervios, koro, zar — you can check out Wikipedia or some other source on ‘culture bound syndromes,’ such as Introduction to Culture-Bound Syndromes in Psychiatric Times, to get a fuller discussion of some of these conditions. The Psychiatric Times piece suggests that there are at least 200 culture-bound syndromes.

One thing I really liked about the New York Times Magazine article, however (and by extension, Watters’ book, I suspect), is that the discussion of ‘culture-bound syndromes’ usually tends to treat other people’s syndromes as ‘culture-bound,’ Western psychological illnesses as not ‘culture-bound.’ Watters’ work points out that Western mental illness is both itself culture-bound and that persuading people to believe in Western-style mental illness can affect the way that psychic disorders manifest.

In fact, even Western history is littered with examples of truly odd and intriguing psychic illnesses that we seem to be vulnerable to for short periods of time. If you’re starved for more examples of culturally induced psychological conditions that include both Western and non-Western versions, you could check out Outbreak: The Encyclopedia of Extraordinary Social Behaviour, also discussed at Mind Hacks. Sounds like a brilliant read, with material like the following cited by Vaughan:

The Fortean Times article has some great excerpts covering an outbreak of feinting in a marching band in 1973 Alabama (a classic case of mass hysteria), an outbreak of cat-like meowing in India in 2004, the 1958 hula-hoop craze, a goblin scare that affect Zimbabwe in 2002, a ‘culture bound syndrome’ with the unusual name of the jumping Frenchmen of Maine from the 18th and 19th centuries, various outbreaks of fears about chemtrails, a giant earthworm hoax that panicked a Texas town in 1993, and a version of Orson Well’s War of the Worlds that caused widespread rioting in Ecuador in 1949.

But I digress simply because the examples themselves are so fascinating…

To return to the New York Times Magazine piece, Watters discusses how a group of psychological anthropologists and cross-cultural psychologists have argued that, just as humans are psychologically and socially diverse, they are diverse, too, when it comes to psychic ailments:

Swimming against the biomedical currents of the time, they have argued that mental illnesses are not discrete entities like the polio virus with their own natural histories. These researchers have amassed an impressive body of evidence suggesting that mental illnesses have never been the same the world over (either in prevalence or in form) but are inevitably sparked and shaped by the ethos of particular times and places.

Between the lines, the article suggests two slightly different, competing explanations for this diversity in psychological illness. On the one hand, the variety might arise because the language of somatization of distress varies from place to place. As one source for Watters’ article argues:

“We might think of the culture as possessing a ‘symptom repertoire’ — a range of physical symptoms available to the unconscious mind for the physical expression of psychological conflict,” Edward Shorter, a medical historian at the University of Toronto, wrote in his book “Paralysis: The Rise and Fall of a ‘Hysterical’ Symptom.” “In some epochs, convulsions, the sudden inability to speak or terrible leg pain may loom prominently in the repertoire. In other epochs patients may draw chiefly upon such symptoms as abdominal pain, false estimates of body weight and enervating weakness as metaphors for conveying psychic stress.”

In Shorter’s explanation, symptoms are a kind of social communication of ‘psychological conflict,’ varying because different eras and areas offer different ‘symptom repertoires,’ different palettes in which to paint one’s distress. In this model, because the community or specialists respond to particular sorts of patient presentation, believing that certai symptoms are especially salient, the disorders quickly conform to the expectations of therapists, whether they wear white coats, tweed coats with arm patches, or ritual body paint.

While this is certainly possible, and maybe even probable in some cases, some psychological disorders seem to be less labile, less liable to renegotiation of the symptoms, although the symptoms do vary slightly across cultures or occur at different rates, have varied rates of recovery, or the like. Some disorders have neurological or neurochemical dynamics that are susceptible, at least in part, to treatment with drugs, so all symptoms may not be so culturally negotiable, although they might still vary in frequency, severity, and trajectory as I’ll discuss. That is, the ‘symptom repertoire’ explanation — which I concede likely explains some of the variation, but not all — demands that psychic illness be a kind of unconscious performance of internal, psychic conflict. The assumption seems to be that universal psychic dilemma — conflict — gets expressed in locally variable argot — symptom.

The second explanation which I find more compelling is implicit in the article, and not fully developed. A more holistic model of variation in psychological illness would concede that, in some cases, symptoms are very malleable, and some symptoms of a disorder may be susceptible to this type of modification-by-expectation, but there might be more intransigent organic dimensions of disorders that still might vary culturally, but not due only to therapists’ expectation. The domain of the ‘cultural’ might be broader and less inherently conscious than just ‘beliefs.’

The case of anorexia nervosa in Hong Kong

Let’s take the case of anorexia nervosa in Hong Kong that Watters discusses. According to Watters, Dr. Sing Lee documented occurrences of a rare form of anorexia in Hong Kong throughout the 1980s and 1990s. Lee’s patients ‘did not intentionally diet nor did they express a fear of becoming fat,’ instead complaining that they felt ‘bloated.’ Then in 1994, a very public case of a girl who had starved herself hit the press, and Dr. Lee noticed a shift in anorexia: the number of cases climbed, and the sufferers began to diet and express fear of becoming fat, just like the American version of the disorder: ‘As the general public and the region’s mental-health professionals came to understand the American diagnosis of anorexia, the presentation of the illness in Lee’s patient population appeared to transform into the more virulent American standard.’

Lee explains how generalized psychological disorder leads to a specific eating disorder: ‘When there is a cultural atmosphere in which professionals, the media, schools, doctors, psychologists all recognize and endorse and talk about and publicize eating disorders, then people can be triggered to consciously or unconsciously pick eating-disorder pathology as a way to express that conflict.’

But is that really all that happened, people talking about anorexia? Was it simply a matter of mental-health professionals inadvertently causing the more benign strain of anorexia in Hong Kong to mutate into the American version? The increase in fat phobia among anorexic sufferers did not occur in a vacuum, I would argue, affected only by mental health specialists. I suspect other Western influences likely also contributed to the shift, including ‘diet’ discourse, maybe even changes in actual diet, media imagery of idealized bodies, and the fitness industry. And what about shifts within this population in anxiety levels, sexuality-related expectations, fashion, socializing, male-female relations, and other more indigenous, though certainly not isolated dynamics? And was there an incursion of the material culture of Western dieting, such as diet drinks, calorie counting techniques or food labelling, or even high-fat foods to both affect body type and to provide a medium in which to express control over oneself. Just as the changing prevalence of anorexia nervosa in the West can’t simply be chalked up to a single cause such as patients’ suggestibility, I doubt we could do the same in Hong Kong. Sure, the anorexia outbreak may be ignited by ‘psychic conflict,’ but why does it take this specific form, and why does the form change in prevalence?

That is, the simple story that therapists gave their patients anorexia is possible, but there are other potential candidate explanations, and we’re quite likely to have an accumulation of cultural shifts that helps to explain the change in Hong Kong. After all, not every Western disorder grows at the same rate simply because therapists talk about them; they intersect with local anxieties, changing lifestyles, even physiological traits.

Western ‘culture’ is not just a set of ideas but a whole constellation of ideas, concepts, images, practices, customs, material culture, technology, and other everyday factors that feed into these disorders, even when they are ‘expressions of of psychological conflict.’ Certainly in terms of global diet and bodily culture, Western ideas are not the only factors affecting global change: technological, commercial, economic, agronomical, demographic, educational, and even mechanical (in terms of access to transport) changes are also influencing how bodies are changing internationally. We shouldn’t be too surprised that disorder, hypervigilant eating becomes more prevalent when food ways are in such a state of upheaval, body images are raining down on these populations, activity patterns are shifting, and so many of the new choices are unhealthy, fattening, and alien.

Without doubt, Western ideas about mental illness are directly affecting expectations of psychic distress around the world; see, for example, Vaughan at Mind Hacks discussing Did Antidepressants Depress Japan?. Here Vaughan highlights another force, one touched on by Watters but not explored; pure mercenary impulses, as drug companies try to persuade new markets that the individuals ‘need’ their products, suffering as they do from disorders of which they were previously unaware. Here, the idea that it’s just the ‘beliefs’ about illness held by therapists and authorities obscures the naked greed that goes into public relations campaigns designed to produced disorder.

My argument is not so much that Watters is wrong, as that culture is not just in the ideas people have about disease; these changes in mental illness are also provoked by the social, technological, and material world, for example, how the export of Western-style education affects childhood elsewhere (and thus illuminates ‘disorders’). When Watters writes the following, I whole-heartedly agree:

In the end, what cross-cultural psychiatrists and anthropologists have to tell us is that all mental illnesses, including depression, P.T.S.D. and even schizophrenia, can be every bit as influenced by cultural beliefs and expectations today as hysterical-leg paralysis or the vapors or zar or any other mental illness ever experienced in the history of human madness. This does not mean that these illnesses and the pain associated with them are not real, or that sufferers deliberately shape their symptoms to fit a certain cultural niche. It means that a mental illness is an illness of the mind and cannot be understood without understanding the ideas, habits and predispositions — the idiosyncratic cultural trappings — of the mind that is its host.

Although I’m a little uncomfortable with the word ‘mind’ in the last sentence, I especially like the end of the passage. Yes, it’s true, you can’t understand a mental illness without understanding a bit about the… well, okay, ‘mind’ of the person suffering. It’s just that it’s not that narrow: you have to understand a bit about the developmental influences on their brain, about the social network that supports or stigmatizes them, the behavioural reserves for unusual behaviour or thoughts… It’s not just about the conscious stories and understandings, but also about the harder-to-pin-down social, behavioural, and developmental factors that affect disease expression.

Watters actually provides a great example of these non-belief cultural factors when he discusses one of the more interesting dilemmas in cross-cultural psychiatry:

The research showed that patients outside the United States and Europe had significantly lower relapse rates — as much as two-thirds lower in one follow-up study. These findings have been widely discussed and debated in part because of their obvious incongruity: the regions of the world with the most resources to devote to the illness — the best technology, the cutting-edge medicines and the best-financed academic and private-research institutions — had the most troubled and socially marginalized patients.

Watters seeks to explain this unexpected gap in treatment by discussing the work of anthropologist Juli McGruder (University of Puget Sound) on families of schizophrenics in Zanzibar. In Zanzibar, schizophrenics are believed to be suffering from intermittent bouts of spirit possession. To cut to the chase, this belief affects those around them, especially family members, which affects how they treat the individual with the condition: ‘With schizophrenia… symptoms are inevitably entangled in a person’s complex interactions with those around him or her. In fact, researchers have long documented how certain emotional reactions from family members correlate with higher relapse rates for people who have a diagnosis of schizophrenia.’ It turns out that interaction patterns with a person possessed by spirits are actually healthier than those of family members in the West who believe the individual has a ‘mental illness.’ In fact, with US families, the more they try to ‘care’ for the schizophrenic family member, the more they fall into an unproductive interaction pattern with the individual with the illness. The issue is not just the belief, but the emotional quality of family interaction with a suffering individual; treat them one way, and it’s not just that you believe they’re different — the individual actually becomes different.

The discussion of trauma and trauma recovery is quite short, but Watters does highlight nicely some of the problems of exporting Western-style treatment to deal with trauma that we expect others to feel.

Behind the promotion of Western ideas of mental health and healing lie a variety of cultural assumptions about human nature. Westerners share, for instance, evolving beliefs about what type of life event is likely to make one psychologically traumatized, and we agree that venting emotions by talking is more healthy than stoic silence. We’ve come to agree that the human mind is rather fragile and that it is best to consider many emotional experiences and mental states as illnesses that require professional intervention. (The National Institute of Mental Health reports that a quarter of Americans have diagnosable mental illnesses each year.) The ideas we export often have at their heart a particularly American brand of hyperintrospection — a penchant for “psychologizing” daily existence.

Even dealing with Australians, I find that this is a huge difference, that the need for hyperintrospection, for obsessive re-tracing of distressing events or conflict, the need for a ‘talking out’ to resolution of issues is simply not shared. And Australian are widely considered to be some of the most culturally similar people to Americans. Certainly, the gap I felt in Brazil was even greater.

I found the conclusion to the article even more surprising, a kind of reverse-diagosis of Americans to suggest that the exportation of American psychiatric health may not be in the interest of the globe:

If our rising need for mental-health services does indeed spring from a breakdown of meaning, our insistence that the rest of the world think like us may be all the more problematic. Offering the latest Western mental-health theories, treatments and categories in an attempt to ameliorate the psychological stress sparked by modernization and globalization is not a solution; it may be part of the problem. When we undermine local conceptions of the self and modes of healing, we may be speeding along the disorienting changes that are at the very heart of much of the world’s mental distress.

I’ll just leave it at this, as I don’t have anything else to add to the conclusion. I heartily recommend the original article, and was genuinely surprised to read something I felt was both engaging (well written) and yet still very thorough (well thought).

21 thoughts on “Exporting American mental illness”

Very much enjoyed your thoughts in my piece. One thing I did want to note is that the book has one long chapter about PTSD (focusing on Western interventions after the tsunami in Sri Lanka) and one long chapter about changing notions of depression in Japan. I didn’t focus on either of these aspects in today’s article because I had already written a short column in the magazine on PTSD when I started this project. I avoided depression in Japan also because the article you site above was also published in the magazine. But both these disorder feature prominently in the book. Few better examples than PTSD and depression for illustrating how our ideas about the mind are spreading across borders. One of my favorite quotes from the book: Alan Young at McGill told me, “PTSD may be the greatest success story of globalization.” Thank you for the thoughtful contribution to the topic and discussion.

Thanks, Ethan, for the response, but more importantly, for the original article. As you can tell (I hope), I really liked it, so much that a short note on it turned into a longer discussion, and wound up keeping me awake until about 1:30 in the morning (hence the typos). Usually, Daniel responds to the medical anthropology-related articles, but I beat him to your piece.

I do look forward to the book, and please feel free to come back to Neuroanthropology if you want to comment on or discuss the publication. I know you’ve got plenty of places to share your thoughts, so we’d even be interested just to link to more from the project.

PTSD is an especially interesting case, I agree. It comes up for me when I teach my human rights course, when we start to discuss justice and reconciliation models from around the world, and the difficulty of using a one-size-fits-all approach to dealing with post-conflict societies. I think it’s always an eye-opener for my students to read some of the first-hand accounts of survivors and what they say they want out of post-conflict tribunals; they quickly realise that not everyone wants the same thing, nor follows the same trajectory of healing.

Thanks very much for this — I found a link to it in another blog, and found it very interesting. I’ve had direct experience of the American export of mental illness, in the form of a letter I received some years ago from a bunch of psychotherapists in Chicago, saying that they were concerned about the mental health of people in Namibia, where I was at the time, and offering to send teams of shrinks to Namibia. I replied to the effect that they would be about as effective as a team of Namibian witchdoctors would be if sent to help with the mental health needs of middle-class suburbanites in Illinois. In either case, they would need to bridge the cultural gap before they could be effective, and that could not be done in a few weeks.

I will buy this book based on this review. I read a great book “Empire of Illusion” that covers many examples of mass illusion in American from sports, politics, and several more. I also know how America is trying to Westernize the rest of the World. This book seems to have a similar take but with the subject of mental health.

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